HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 90 WINTERGREEN DRIVE 7/3/2023 Commonwealth of Massachusetts
City/Town of
System Pumping Record 31.0
Form 4 10'0
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must.be substantially the same as that provided here. Before using this form, check with yo
local Board of Health to determine the form they use. The System Pumping.Record must be submitted
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15,351, — .-- -
HOUSE: front back side rea le righ
A. Facility Information BUILDING: front ba.ck side rear left righ
Important:When
DECK: under
filling out forms 1. S stem Location:
on the computer, 0 /,wrl
use only the lab
key to move your Address
cursor-do not
use the return City/Town ��- Stale'V
key. Zip Code
2. Syst Owner.
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Name
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Address (if different from location)
City/Town . Stat Zip Code
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Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date yGallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
g ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Dave Tiney Mass 1AA95E
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L ati where contents were disposed.
i GLS
Signature of Haul Date
Signature of Receiving Facility(or allach facility receipt) Dale
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